From the Guidelines
Eosinophilic esophagitis (EE) triggers are primarily driven by food antigens and aeroallergens, with the most common food triggers being dairy, wheat, eggs, soy, nuts, fish, and shellfish, as supported by the technical review on the management of EE by the AGA Institute and the Joint Task Force on Allergy-Immunology Practice Parameters 1.
Key Triggers
- Food allergens: dairy, wheat, eggs, soy, nuts, fish, and shellfish, which account for approximately 75% of cases
- Environmental factors: aeroallergens like pollen, dust mites, and mold, which may cause seasonal flares
- Acid reflux: can exacerbate EE by damaging the esophageal lining
Management Approach
The management of EE typically involves a combination of medical therapies and dietary modifications.
- Proton pump inhibitors (PPIs) like omeprazole 20-40mg daily can help reduce esophageal eosinophilia and alleviate symptoms
- Topical steroids such as fluticasone 440-880mcg twice daily or budesonide 1mg twice daily can help reduce inflammation and eosinophilic infiltration
- Biologic therapies like dupilumab 300mg every two weeks may be considered for severe cases
- Dietary elimination: removing the top 4-6 allergens for 6-8 weeks, then systematically reintroducing foods while monitoring symptoms
Underlying Mechanism
The underlying mechanism of EE involves an allergic immune response where eosinophils infiltrate the esophageal tissue, causing inflammation, tissue remodeling, and the characteristic symptoms of dysphagia, food impaction, and chest pain, as described in the technical review by the AGA Institute and the Joint Task Force on Allergy-Immunology Practice Parameters 1.
Personalized Approach
Identifying personal triggers through food journals and allergy testing can help manage symptoms effectively, and patients should work closely with their healthcare provider to develop a personalized treatment plan, as recommended by the technical review 1.
From the Research
EE Triggers
- Eosinophilic esophagitis (EE) is a food antigen-mediated disorder of the esophagus characterized by eosinophil predominant inflammation and symptoms of esophageal dysfunction 2
- The most commonly involved foods in EE include milk, eggs, nuts, beef, wheat, fish, shellfish, corn, and soy; however, almost all foods have been implicated 3
- Foods that are commonly eliminated, especially milk, are also nutrient-dense and therefore their elimination may result in inadequate nutrient intake or deficiencies without careful diet planning to include nutritionally comparable and safe food substitutes 2
- Dietary antigen elimination induces clinical and histological remission in patients with EE, and foods can be reintroduced sequentially to identify specific food triggers 2
- Typical allergy tests are not effective for diagnosis of EE because the allergic reaction involved in EE is non-IgE mediated, and complete elimination of all foods is often required 3
- The diagnosis of EE requires a biopsy of the esophagus, and repeat endoscopy with biopsy is often necessary to assess the response to treatment 3, 4
Treatment Options
- Current therapies for EE include proton pump inhibitors, topical steroid preparations, dietary therapy with amino acid formula or empirical food elimination, and endoscopic dilation 4
- Proton pump inhibitor therapy is associated with a histologic response in patients with EE, and twice-daily PPI is associated with higher EE histologic response rates than once-daily regimen 5, 6
- Topical corticosteroid treatment is associated with histologic remission in patients with EE, and patients with esophageal narrowing may require dilation 4
Diagnosis and Assessment
- The diagnosis of EE requires a biopsy of the esophagus, and typical allergy tests are not effective for diagnosis of EE because the allergic reaction involved in EE is non-IgE mediated 3
- Objective assessment of therapeutic response typically requires endoscopy with biopsy, and repeat endoscopy with biopsy is often necessary to assess the response to treatment 3, 4